ramipril

ramipril

(ra mi' pril)

Altace

Pregnancy Category C (first trimester)

Pregnancy Category D (second and third trimesters)

Drug classes

Antihypertensive

ACE inhibitor

Therapeutic actions

Ramipril blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.

Indications

·        Treatment of hypertension alone or in combination with thiazide-type diuretics

·        Treatment of CHF in stable patients in the first few days after MI

·        To decrease the risk of MI, stroke, death from CV disease in patients at risk for developing CAD

Contraindications and cautions

·        Contraindicated with allergy to ramipril, pregnancy (embryocidal in preclinical studies).

·        Use cautiously with impaired renal function, CHF, salt or volume depletion, lactation.

Available forms

Capsules—1.25, 2.5, 5, 10 mg

Dosages

ADULTS

·        Hypertension: Initial dose, 2.5 mg PO daily. Adjust dose according to BP response, usually 2.5–20 mg/day as a single dose or in two equally divided doses. Discontinue diuretic 2–3 days before beginning therapy; if not possible, administer initial dose of 1.25 mg.

·        CHF: Initial dose, 2.5 mg PO bid; if patient becomes hypotensive, 1.25 mg PO bid may be used while adjusting up to target dose of 5 mg PO bid; increase dose q 3 wk until target dose is reached.

·        Decrease risk of CV events: Initial dose, 2.5 mg PO once daily for 1 wk, then 5 mg PO once daily for next 3 wk; for maintenance 10 mg PO daily.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS AND PATIENTS WITH RENAL IMPAIRMENT

Excretion is reduced in renal failure; use smaller initial dose, 1.25 mg PO daily in patients with creatinine clearance < 40 mL/min; dosage may be titrated upward until pressure is controlled or a maximum of 5 mg/day.

Pharmacokinetics

Route	Onset	Peak	Duration
Oral	1–2 hr	1–4 hr	24 hr

Metabolism: Hepatic; T_1/2: 13–17 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Feces, urine

Adverse effects

·        CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt- or volume-depleted patients, syncope

·        Dermatologic: Rash, pruritus, pemphigoid-like reaction, photosensitivity, erythema multiforme, Stevens-Johnson syndrome

·        GI: Gastric irritation, aphthous ulcers, dysgeusia, cholestatic jaundice, hepatocellular injury, anorexia, constipation, pancreatitis

·        GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency

·        Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia

·        Other: Cough, malaise, dry mouth, lymphadenopathy, angioedema

Interactions

Drug-drug

·        Exacerbation of cough if taken with capsaicin

·        Increased serum levels and increased toxicity with lithium; monitor patient closely

Drug-food

·        Rate of absorption is decreased with food

Drug-lab test

·        False-positive test for urine acetone

Nursing considerations

Assessment

·        History: Allergy to ramipril, impaired renal function, CHF, salt or volume depletion, pregnancy, lactation

·        Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, LFTs, renal function tests, CBC and differential

Interventions

·        Discontinue diuretic for 2–3 days before beginning therapy, if possible, to avoid severe hypotensive effect.

·        Open capsules and sprinkle contents over a small amount of applesauce or mix in applesauce or water if patient has difficulty swallowing capsules. Mixture is stable for 24 hr at room temperature and 48 hr if refrigerated.

·        WARNING: Alert surgeon and mark chart that ramipril is being used; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.

·        Monitor patient closely for falling BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea) because excessive hypotension may occur.

·        Reduce dosage in patients with impaired renal function.

Teaching points

·        Do not stop taking without consulting your health care provider.

·        Be careful in any situation that may lead to a drop in blood pressure (diarrhea, sweating, vomiting, dehydration); if light-headedness or dizziness should occur, consult your health care provider.

·        You may experience these side effects: GI upset, loss of appetite, change in taste perception (transient) mouth sores (frequent mouth care may help); rash; fast heart rate; dizziness, light-headedness (transient; change position slowly, and limit your activities to those that do not require alertness and precision).

·        Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing.

Adverse effects in Italic are most common; those in Bold are life-threatening.